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stress cardiomyopathy; Takotsubo cardiomyopathy; broken heart syndrome; transient apical ballooning syndrome; stress-induced cardiomyopathy; Gebrochenes-Herz-Syndrome; myocardial infarction with nonobstructive coronary arteries; MINOCA

Etiology: - emotional stress - may be more common in women with neurologic disorders or psychiatric disorders [9] - ischemic etiology in > 64% [15] Epidemiology: - 95% of cases in women, mean age 63 Pathology: 1) myocardial stunning mediated by high circulating catecholamines 2) non-ischemic cardiomyopathy 3) sudden, transient weakening of the myocardium 4) low LVEF (mean 20%) 5) LV dyskinesis or akinesis - transient LV systolic dysfunction & LV diastolic dysfunction involving the apex & midventricle [10] 6) normal coronary arteries or minimal disease 7) No coronary vasopasm 8) mononuclear inflammatory infiltrate Clinical manifestations: - patients often present with chest pain Laboratory: 1) serum creatine kinase & creatine kinase MB normal or mildly elevated 2) serum troponin I normal or mildly elevated 3) elevated plasma catecholamines - plasma metanephrines for pheochromocytoma (> 3 nmol/L) [11] Special laboratory: - electrocardiogram: a) marked QT prolongation b) deep T-wave inversion c) ST segment elevation may be present - coronary angiography - left ventricular apical ballooning is present - no significant coronary artery stenosis - echocardiogram (video) [10] - left ventricular thrombus in 5% [4] - transient wall motion abnormalities of the cardiac apex Radiology: - chest X-ray consistent with congestive heart failure - ventriculography (images & video) [10] - MRI of adrenals if pheochromocytoma suspected [11] Differential diagnosis: - acute coronary syndrome, myocardial infarction - cardiac syndrome X - exertional chest pain - baseline lateral ST segment depression may be observed - echocardiogram normal [6] Complications: - acute heart failure - ventricular arrhythmias - ventricular rupture - pericarditis in recovery phase [6,8] - cardiogenic shock is much more common after myocardial infarction (MI) - respiratory failure more common in Takotsubo cardiomyopathy shock, - cardiac arrest & kidney injury more common in MI shock [13] - ~ 1/6 of patients with Takotsubo syndrome also has cancer, most commonly breast cancer or gastrointestinal cancer [14] Management: - follow protocols for evaluating & transporting patients with acute coronary syndrome - admission to cardiology service - treatment options are empirical & supportive - AVOID adrenergic agonists - ACE inhibitor (case report) [10] - if hemodynamics permit, beta blockers seem to be helpful - left ventricular thrombus requires anticoagulation [4] - prognosis: recovery in 14-28 days

General

cardiomyopathy

References

  1. Journal Watch 25(6):47, 2005 Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005 Feb 10;352(6):539-48. PMID: 15703419
  2. Wikipedia: Takotsubo cardiomyopathy http://en.wikipedia.org/wiki/Takotsubo_cardiomyopathy
  3. Virani SS et al Takotsubo Cardiomyopathy, or Broken-Heart Syndrome Tex Heart Inst J. 2007; 34(1): 76-79. PMID: 17420797 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1847940/
  4. Tomich EB and Brown DF Medscape: eMedicine: Takotsubo Cardiomyopathy http://emedicine.medscape.com/article/1513631-overview
  5. Mayo Clinic: Broken Heart Syndrome http://www.mayoclinic.com/health/broken-heart-syndrome/DS01135
  6. Medical Knowledge Self Assessment Program (MKSAP) 16, 18 American College of Physicians, Philadelphia 2012, 2018.
  7. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008 Mar;155(3):408-17. PMID: 18294473
  8. Maruyama T, Hanaoka T, Nakajima H. Acute pericarditis in the recovery phase of transient left ventricular apical ballooning syndrome (takotsubo cardiomyopathy). Intern Med. 2007;46(22):1857-60. Epub 2007 Nov 16 PMID: 18025768
  9. Templin C Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med 2015; 373:929-938. September 3, 2015 PMID: 26332547 http://www.nejm.org/doi/full/10.1056/NEJMoa1406761
  10. Maiti A, Dhoble A. Takotsubo Cardiomyopathy. N Engl J Med 2017; 377:e24. October 19, 2017 PMID: 29045209 http://www.nejm.org/doi/full/10.1056/NEJMicm1615835
  11. Loscalzo J, Roy N, Shah RV et al Case 8-2018: A 55-Year-Old Woman with Shock and Labile Blood Pressure. N Engl J Med 2018; 378:1043-1053. March 15, 2018 PMID: 29539275 http://www.nejm.org/doi/full/10.1056/NEJMcpc1712225
  12. Sharkey SW. A Clinical Perspective of the Takotsubo Syndrome. Heart Fail Clin. 2016 Oct;12(4):507-20. Review. PMID: 27638021
  13. Vallabhajosyula S, Dunlay SM, Murphree DH Jr et al. Cardiogenic shock in Takotsubo cardiomyopathy versus acute myocardial infarction: An 8-year national perspective on clinical characteristics, management, and outcomes. JACC Heart Fail 2019 Jun; 7:469. PMID: 31078481 - Tehrani BN, Rosner C, Sinha SS. et al. Not all shock is created equal: Developing a standardized treatment approach for cardiogenic shock. JACC Heart Fail 2019 Jun; 7:477 PMID: 31078478
  14. Cammann VL, Sarcon A, Ding KJ Clinical Features and Outcomes of Patients With Malignancy and Takotsubo Syndrome: Observations From the International Takotsubo Registry. J Am Heart Assoc. 2019;8. July 17 PMID: 31311438 Free Article https://www.ahajournals.org/doi/10.1161/JAHA.118.010881
  15. Reynolds HR et al. Coronary optical coherence tomography and cardiac magnetic resonance imaging to determine underlying causes of MINOCA in women. Circulation 2020 Nov 14 PMID: 33191769 https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.120.052008
  16. Brady MP Keys to Diagnosing Broken Heart Syndrome (Takotsubo Cardiomyopathy). Medscape. Jan 27, 2021 https://reference.medscape.com/slideshow/broken-heart-syndrome-6012067